Welcome Registration

Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you have about your pet’s health. Please fill out this form and circle answer when appropriate to ensure the best care possible. Thank you and welcome to our practice!

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Client

Owner

Primary Phone

Spouse

Secondary Phone

E-mail

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Emergency Contact Details

Emergency Contact Name

Emergency Contact Number

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Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please Select

Please Select

United States

Afghanistan

Albania

Algeria

American Samoa

Andorra

Angola

Anguilla

Antigua and Barbuda

Argentina

Armenia

Aruba

Australia

Austria

Azerbaijan

The Bahamas

Bahrain

Bangladesh

Barbados

Belarus

Belgium

Belize

Benin

Bermuda

Bhutan

Bolivia

Bosnia and Herzegovina

Botswana

Brazil

Brunei

Bulgaria

Burkina Faso

Burundi

Cambodia

Cameroon

Canada

Cape Verde

Cayman Islands

Central African Republic

Chad

Chile

China

Christmas Island

Cocos (Keeling) Islands

Colombia

Comoros

Congo

Cook Islands

Costa Rica

Cote d'Ivoire

Croatia

Cuba

Cyprus

Czech Republic

Democratic Republic of the Congo

Denmark

Djibouti

Dominica

Dominican Republic

Ecuador

Egypt

El Salvador

Equatorial Guinea

Eritrea

Estonia

Ethiopia

Falkland Islands

Faroe Islands

Fiji

Finland

France

French Polynesia

Gabon

The Gambia

Georgia

Germany

Ghana

Gibraltar

Greece

Greenland

Grenada

Guadeloupe

Guam

Guatemala

Guernsey

Guinea

Guinea-Bissau

Guyana

Haiti

Honduras

Hong Kong

Hungary

Iceland

India

Indonesia

Iran

Iraq

Ireland

Israel

Italy

Jamaica

Japan

Jersey

Jordan

Kazakhstan

Kenya

Kiribati

North Korea

South Korea

Kosovo

Kuwait

Kyrgyzstan

Laos

Latvia

Lebanon

Lesotho

Liberia

Libya

Liechtenstein

Lithuania

Luxembourg

Macau

Macedonia

Madagascar

Malawi

Malaysia

Maldives

Mali

Malta

Marshall Islands

Martinique

Mauritania

Mauritius

Mayotte

Mexico

Micronesia

Moldova

Monaco

Mongolia

Montenegro

Montserrat

Morocco

Mozambique

Myanmar

Nagorno-Karabakh

Namibia

Nauru

Nepal

Netherlands

Netherlands Antilles

New Caledonia

New Zealand

Nicaragua

Niger

Nigeria

Niue

Norfolk Island

Turkish Republic of Northern Cyprus

Northern Mariana

Norway

Oman

Pakistan

Palau

Palestine

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Pitcairn Islands

Poland

Portugal

Puerto Rico

Qatar

Republic of the Congo

Romania

Russia

Rwanda

Saint Barthelemy

Saint Helena

Saint Kitts and Nevis

Saint Lucia

Saint Martin

Saint Pierre and Miquelon

Saint Vincent and the Grenadines

Samoa

San Marino

Sao Tome and Principe

Saudi Arabia

Senegal

Serbia

Seychelles

Sierra Leone

Singapore

Slovakia

Slovenia

Solomon Islands

Somalia

Somaliland

South Africa

South Ossetia

South Sudan

Spain

Sri Lanka

Sudan

Suriname

Svalbard

eSwatini

Sweden

Switzerland

Syria

Taiwan

Tajikistan

Tanzania

Thailand

Timor-Leste

Togo

Tokelau

Tonga

Transnistria Pridnestrovie

Trinidad and Tobago

Tristan da Cunha

Tunisia

Turkey

Turkmenistan

Turks and Caicos Islands

Tuvalu

Uganda

Ukraine

United Arab Emirates

United Kingdom

Uruguay

Uzbekistan

Vanuatu

Vatican City

Venezuela

Vietnam

British Virgin Islands

Isle of Man

US Virgin Islands

Wallis and Futuna

Western Sahara

Yemen

Zambia

Zimbabwe

Other

Country

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How did you learn about our Hospital?

Royalton Recorder

The Post

Mimi’s

Drive-by

Event

Internet

Word of Mouth / Friend / Family

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Please Specify Name, If Word of Mouth / Friend / Family

Name

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I grant permission to use my Pet’s Photograph for use in Newspapers, Facebook, Social Media, and/or our Website.

Yes

No

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Number of Pets in your Home

Dogs

Cats

Other

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Precautions to be aware of with your pet?

Yes

No

Current on Rabies?

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Patient

Name of Pet

Age or Date of Birth

Male

Female

Sex

Yes

No

Unknown

Fixed

Canine

Feline

Species

Breed

Color

Previous Veterinarian

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AUTHORIZATION

I hereby authorize this hospital’s veterinarian to examine, prescribe for or treat the above noted pet. I assume complete responsibility for all charges incurred in the care of this pet. I also understand that these charges will be paid at the time of release and that a deposit will be required for surgical treatment. We do not offer payment plans. For your convenience, NRAH accepts cash, personal check or credit card (Visa, MC, Discover, & Care Credit). We charge a $30.00 service fee for any returned check.

Estimates include items our staff will most likely require to treat and care for your pet during his/her treatment and hospitalization. Please understand the estimate is an approximation only. The final cost may vary from the estimate provided. We routinely provide written estimates for all hospitalized patients, and your medical care team will discuss that estimate with you prior to admission. Our team will make every effort to inform you of ongoing costs; however, it is your responsibility to ask a staff member for daily updates on your invoice.

Alternative Finance Plans: NRAH offers an alternative payment option for our clients through Care Credit. If you choose to use this plan, NRAH is in no way affiliated with this program or organization. The financial relationship is between you and the lender – not our hospital.

Pet Insurance Providers are available. NRAH is not involved with insurance billing. If you choose to use a provider, the financial relationship is between you and the lender, not our hospital. Also, understand that these charges will be paid at the time of release and that a deposit will be required for surgical treatment.